There was a time in the history of the automobile when there were no speed limits, license plates, or stoplights. And it didn’t matter, because there were only one or two cars in town. As roads got crowded and accidents happened, the rules began to accumulate. AHIMA CEO Lynne Thomas Gordon says that’s what’s happening now with electronic health records. Her HIMSS14 session will focus on “rules of the road” for the increasingly crowded health information superhighway. The session is titled “The Next Frontier: Quality Clinical Documentation and Health Data Integrity” and will take place Tuesday, Feb. 25 at 8:30-9:30 a.m.

“Right now we’re at the tipping point—we’ve gone from the horse and buggy to the Model T,” says Gordon, who joined AHIMA as CEO in late 2011, after holding leadership roles in several hospitals. She says that with the profusion of uses for the information in EHRs, insuring its integrity should be a top priority for those who generate it.

In her session, she plans to:

  • Explain how AHIMA and its members have developed and implemented best practices and standards in health data and information management as part of a growing effort toward organization-wide information governance.
  • Identify how clinicians and other health care professionals can facilitate and assure accurate clinical data capture and documentation as integral components of EHRs.
  • Describe approaches to clinical data collection and documentation as part of an overall information governance infrastructure.

She’ll discuss tricky issues like the use of the copy-paste function, how to identify authorship of specific pieces of data, and making sure entries are made in the correct record. She’ll also address the potential wild card of patient-supplied information, such as from personal health records or fitness-tracking devices.
AHIMA is working on creating a framework for data integrity that all stakeholders can adopt before they get too far into EHR implementation and data sharing. Later this year, it plans to issue a report benchmarking healthcare data governance compared with other industries like banking. The report will encompass not just clinical information, but human resource files, patient accounting records—basically any data maintained by a health care provider.

AHIMA hopes to have a model data integrity policy out by the end of the year. “HIMSS is the pipes, and AHIMA is the water,” Gordon says. “You want the water to be trusted, safe, secure, the right temperature. How do you make sure the water can be trusted? Since we don’t have these guidelines, everyone’s trying to do the right thing, but because of how much is on their plates right now, they need guidance.”

 

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